Motivators of becoming and staying a neurosurgeon in the Netherlands: a survey and focus group.

OBJECTIVE: The aim of this study was to gain insight in motivators and demotivators of the Dutch neurosurgical residents and neurosurgeons. METHODS: A mixed method study was conducted. A survey was sent by the Dutch Neurosurgical Society to all Dutch neurosurgeons and residents in the framework of the yearly national quality conference. The focus groups were held during the Dutch national training days for neurosurgical residents. Baseline statistics were made of all survey data. Focus group recordings were transcribed verbatim and open coded in a constant comparative manner. RESULTS: The survey yielded a response rate of 47.3% of neurosurgeons and 72.5% of residents. 42.5% of residents participated in the focus groups. Overall, motivators according to residents and neurosurgeons were divided between autonomous and controlled motivation. For residents, the motivators to become a neurosurgeon were mostly patient-centered. Neurosurgeons had the same general motivators as residents. Around one-third of neurosurgeons considered ending their career as a neurosurgeon. Among residents, 9.5% considered quitting residency. Neurosurgeons and residents indicated that no time for their family life, increased administrative burden and non-patient-related tasks were reasons to consider leaving the profession. Also, less perceived respect from patients and society was a reason to consider ending their career as a neurosurgeon. CONCLUSION: Neurosurgeons and residents in neurosurgery are mostly motivated by intrinsic motivators. Factors such as administrative burden, less perceived respect from patients and society, and increase in non-patient-related tasks are large demotivators for both neurosurgeons and residents.

Meningiomas in three male-to-female transgender subjects using oestrogens/progestogens and review of the literature.

Sex hormones have been proposed as a possible risk factor for the development and growth of meningiomas. Hormonal therapy plays a fundamental role in the treatment of male-to-female transgenders and needs to be continued after sex reassignment surgery. Usually, this treatment leads to no adverse events; however, its impact on hormone-related tumours such as meningiomas has not yet been investigated thoroughly. We searched our cohort of 2810 male-to-female transgender persons, who have been treated between 1975 and 2010, for patients with meningiomas. Additionally, we conducted a literature search in PubMed and EMBASE. We found three patients who developed a meningioma in male-to-female transgenders in addition to five other who have been described in the literature. These findings support the role of female sex hormones in the development and growth of meningiomas. This might be an underrepresentation, because there is no standard protocol for screening for meningiomas in this population and meningiomas can remain asymptomatic for several years. We observed regression of multiple meningiomas in one of these three cases after discontinuation of hormonal treatment. The decision to stop or continue cross-sex hormone therapy in these particular patients should be carefully reconsidered individually.

Toward diversity-responsive medical education: taking an intersectionality-based approach to a curriculum evaluation.

Recent years have seen a rise in the efforts to implement diversity topics into medical education, using either a 'narrow' or a 'broad' definition of culture. These developments urge that outcomes of such efforts are systematically evaluated by mapping the curriculum for diversity-responsive content. This study was aimed at using an intersectionality-based approach to define diversity-related learning objectives and to evaluate how biomedical and sociocultural aspects of diversity were integrated into a medical curriculum in the Netherlands. We took a three-phase mixed methods approach. In phase one and two, we defined essential learning objectives based on qualitative interviews with school stakeholders and diversity literature. In phase three, we screened the written curriculum for diversity content (culture, sex/gender and class) and related the results to learning objectives defined in phase two. We identified learning objectives in three areas of education (medical knowledge and skills, patient-physician communication, and reflexivity). Most diversity content pertained to biomedical knowledge and skills. Limited attention was paid to sociocultural issues as determinants of health and healthcare use. Intersections of culture, sex/gender and class remained mostly unaddressed. The curriculum's diversity-responsiveness could be improved by an operationalization of diversity that goes beyond biomedical traits of assumed homogeneous social groups. Future efforts to take an intersectionality-based approach to curriculum evaluations should include categories of difference other than culture, sex/gender and class as separate, equally important patient identities or groups.

miR-200a-mediated suppression of non-muscle heavy chain IIb inhibits meningioma cell migration and tumor growth in vivo.

miR-200a has been implicated in the pathogenesis of meningiomas, one of the most common central nervous system tumors in humans. To identify how miR-200a contributes to meningioma pathogenesis at the molecular level, we used a comparative protein profiling approach using Gel-nanoLC-MS/MS and identified approximately 130 dysregulated proteins in miR-200a-overexpressing meningioma cells. Following the bioinformatic analysis to identify potential genes targeted by miR-200a, we focused on the non-muscle heavy chain IIb (NMHCIIb), and showed that miR-200a directly targeted NMHCIIb. Considering the key roles of NMHCIIb in cell division and cell migration, we aimed to identify whether miR-200a regulated these processes through NMHCIIb. We found that NMHCIIb overexpression partially rescued miR-200a-mediated inhibition of cell migration, as well as cell growth in vitro and in vivo. Moreover, siRNA-mediated silencing of NMHCIIb expression resulted in a similar migration phenotype in these cells and inhibited meningioma tumor growth in mice. Taken together, these results suggest that NMHCIIb might serve as a novel therapeutic target in meningiomas.

Neurocognitive functioning and health-related quality of life in patients with radiologically suspected meningiomas.

Few data are available concerning the neurocognitive outcome and health-related quality of life (HRQOL) following neurosurgery in meningioma patients, and even less is known about neurocognitive functioning and HRQOL in untreated patients with stable lesions. The present study aims at quantifying the nature and extent of neurocognitive deficits and HRQOL in suspected WHO grade I meningioma patients who have not received surgery and/or radiotherapy and compare outcome to that of healthy controls. Neurocognitive functioning was assessed by using a standardized test battery in 21 radiologically suspected WHO grade I meningioma patients with a wait-and-scan approach. HRQOL was assessed with the MOS SF-36 questionnaire. These patients were matched for age, sex, and education with 21 healthy controls. Associations between neurocognitive functioning on the one hand and HRQOL and tumor characteristics on the other were determined. Compared to healthy controls, meningioma patients had lower psychomotor speed (p = 0.011) and working memory capacity (p = 0.034) and furthermore attained lower levels of self-perceived general health and vitality. Neurocognitive functioning in untreated patients was not related to tumor volume, edema or tumor lateralization. No correlations were found between psychomotor speed or working memory and HRQOL. Untreated meningioma patients with stable lesions have limitations in neurocognitive functioning and HRQOL. In deciding upon a treatment strategy these reductions in functioning should be taken into consideration and communicated with the patient.

Effects of physician-based emergency medical service dispatch in severe traumatic brain injury on prehospital run time.

INTRODUCTION: Prehospital care by physician-based helicopter emergency medical services (P-HEMS) may prolong total prehospital run time. This has raised an issue of debate about the benefits of these services in traumatic brain injury (TBI). We therefore investigated the effects of P-HEMS dispatch on prehospital run time and outcome in severe TBI. METHODS: Prehospital run times of 497 patients with severe TBI who were solely treated by a paramedic EMS (n = 125) or an EMS/P-HEMS combination (n = 372) were retrospectively analyzed. Other study parameters included the injury severity score (ISS), Glasgow Coma Scale (GCS), prehospital endotracheal intubation and predicted and observed outcome rates. RESULTS: Patients who received P-HEMS care were younger and had higher ISS values than solely EMS-treated patients (10%; P = 0.04). The overall prehospital run time was 74 ± 54 min, with similar out-of-hospital times for EMS and P-HEMS treated patients. Prehospital endotracheal intubation was more frequently performed in the P-HEMS group (88%) than in the EMS group (35%; P<0.001). The prehospital run time for intubated patients was similar for P-HEMS (66 (51-80)min) and EMS-treated patients (59 (41-88 min). Unexpectedly, mortality probability scores and observed outcome scores were less favourable for EMS-treated patients when compared to patients treated by P-HEMS. CONCLUSION: P-HEMS dispatch does not increase prehospital run times in severe TBI, while it assures prehospital intubation of TBI patients by a well-trained physician. Our data however suggest that a subgroup of the most severely injured patients received prehospital care by an EMS, while international guidelines recommend advanced life support by a physician-based EMS in these cases.

Feasibility of online seizure detection with continuous EEG monitoring in the intensive care unit.

INTRODUCTION: Continuous EEG (cEEG) is of great interest in view of the reported high prevalence of non-convulsive seizures on intensive care units (ICUs). Here, we describe our experiences applying a seizure warning system using cEEG monitoring. METHODS: Fifty comatose ICU patients were included prospectively and monitored. Twenty-eight patients had post-anoxic encephalopathy (PAE) and 22 had focal brain lesions. A measure of neuronal interactions, synchronization likelihood, was calculated online over 10s EEG epochs and instances when the synchronization likelihood exceeded a threshold where marked as seizures. RESULTS: Five patients developed seizures. Our method detected seizures in three patients, in the other patients seizures were missed because of they were non-convulsive and had a focal character. The average false positive rate was 0.676/h. DISCUSSION: This is our first attempt to implement online seizure detection in the ICU. Despite problems with artifacts and that we missed focally oriented seizures, we succeeded in monitoring patients online. Given the relatively high occurrence of seizures, online seizure detection with cEEG merits further development for use in ICUs.

Prehospital endotracheal intubation in patients with severe traumatic brain injury: guidelines versus reality.

The international Brain Trauma Foundation guidelines recommend prehospital endotracheal intubation in all patients with traumatic brain injury (TBI) and a Glasgow Coma Scale (GCS)< or =8. Close adherence to these guidelines is associated with improved outcome, but not all severely injured TBI patients receive adequate prehospital airway support. Here we hypothesized that guideline adherence varies when skills are involved that rely on training and expertise, such as endotracheal intubation. We retrospectively studied the medical records of CT-confirmed TBI patients with a GCS< or =8 who were referred to a level 1 trauma centre in Amsterdam (n=127). Records were analyzed for demographic parameters, prehospital treatment modalities, involvement of an emergency medical service (EMS) and respiratory and metabolic parameters upon arrival at the hospital. Patients were mostly male, aged 45+/-21 years with a median injury severity score (ISS) of 26. Of all patients for whom guidelines recommend endotracheal intubation, only 56% were intubated. In 21 out of 106 severe cases an EMS was not called for, suggesting low guideline adherence. Especially those TBI patients treated by paramedics tended to develop higher levels of stress markers like glucose and lactate. We observed a low degree of adherence to intubation guidelines in a Dutch urban area. Main reasons for low adherence were the unavailability of specialized care, scoop and run strategies and absence of a specialist physician in cases where intubation was recommended. The discrepancy between guidelines and reality warrants changing practice to improve guideline compliance and optimize outcome in TBI patients.

Imaging-documented repeated intratumoral hemorrhage in vestibular schwannoma: a case report.

Intratumoral hemorrhage in vestibular schwannomas is rare. Symptoms often have an acute onset and include headache, nausea, vomiting, vertigo, and depressed consciousness. Intratumoral hemorrhage is probably caused by vascular fragility associated with tumor characteristics and growth. With hemorrhage in VS being rare, repeated hemorrhage has only been reported twice, and on clinical grounds only. The present report details the case of acute neurological deterioration in a patient with repeated intratumoral hemorrhage inside a vestibular schwannoma with computed tomography and magnetic resonance imaging confirmation. To our knowledge, repeated hemorrhage in vestibular schwannoma with radiological confirmation has not been reported before.

[Subdural hematoma and depression]. / Subduraal hematoom en depressie.

BACKGROUND: Chronic subdural haematoma (csdh) is difficult to diagnose because patients with this disorder, in particular the elderly, present with such a wide variety of symptoms. The subject of this case study is an 89-year-old man with a history of csdh who presented with severe depressive symptoms with psychotic features and who in the end turned out to have a recurrence of csdh. An integrated past and who present with psychiatric problems and fall frequently. When a patient presents with such symptoms, one needs to be on the look-out for a recurrence of csdh.

Acquired encephaloceles and epilepsy in osteopetrosis.

Osteopetrosis is a condition in which there is a defect in bone resorption by osteoclasts. With thickening of the skull and skull base, the cranial capacity becomes compromised and skull foramina gradually occlude, resulting in a wide range of neurological symptoms and signs. We present a case of autosomal dominant osteopetrosis with temporal lobe epilepsy and nasal obstruction due to acquired bifrontal encephaloceles associated with a decreased intracranial capacity. Neurosurgical reconstruction of the frontal skull base alleviated the symptoms of epilepsy and nasal obstruction.

Cerebral microdialysis and positron emission tomography after surgery for aneurysmal subarachnoid hemorrhage in grade I patients.

BACKGROUND: Using cerebral microdialysis, baseline values for energy-related chemical markers have been reported in awake patients. Radionuclide studies have demonstrated a locally decreased metabolism, thought to be the result of brain retraction. These baseline values, however, may not be applicable to patients after surgical aneurysm repair following a subarachnoid hemorrhage (SAH). We assessed metabolic chemical marker levels in World Federation of Neurological Surgeons Committee (WFNS) grade I SAH patients after aneurysm surgery and compared them with previously reported baseline values. METHODS: In 5 WFNS grade I SAH patients, energy-related chemical marker levels were obtained using microdialysis in the area of brain retraction after aneurysm surgery. In addition, an [(18)F]2-deoxy-d-glucose positron emission tomography (FDG-PET) was performed. RESULTS: The FDG-PET showed a decrease of glucose metabolism in the frontotemporal area. Comparing the mean values for chemical markers of this study with reported baseline values, the most striking difference was a mild decrease of pyruvate and an increase of the lactate/pyruvate ratio. In individual patients, some markers indicated possible ischemia. A consistent pattern or ischemic profile for all markers, however, was not found. CONCLUSION: FDG-PET scanning confirmed postoperative metabolic changes found in previous studies. Mean interstitial chemical marker levels ranged from normal to mildly deviant compared with reference chemical marker levels for awake patients and are likely to be applicable in SAH patients after aneurysm repair.

Metastatic adenocarcinoma in the cerebellopontine angle, presenting as a meningioma: a case report of rare occurrence.

We present the case of a 36-year old woman who was referred to our hospital with an 8 weeks history of walking difficulties, nausea and vomiting, diminished hearing on the right side and diplopia. On Magnetic Resonance-Imaging (MRI) a tumour in the right cerebellopontine angle (CPA) was diagnosed. The tumour was resected and histopathological examination revealed an adenocarcinoma, suspicious for a metastasis from carcinoma of the breast considering the aspect of the cells, immunochemical profile, age and gender of the patient. No primary tumour was found. In cases without histopathological diagnosis, radiosurgery should be withheld when there is doubt about the clinical or radiological diagnosis.

[Neuromonitoring of patients following severe brain trauma]. / Neuromonitoring bij patiënten na ernstig traumatisch hersenletsel.

To a considerable extent, the neurological outcome of patients with severe brain trauma is determined by the primary injury caused by the accident. Substantial progress has been made in our understanding of the pathophysiological processes resulting in secondary brain damage after brain trauma, partly as a result of the introduction of advanced techniques of neuromonitoring. Early recognition and treatment of the symptoms leading to this type of brain damage seems crucial to the effort to improve the neurological outcome in these patients. Useful modern neuromonitoring techniques include: measurement of the intracranial and cerebral perfusion pressure and continuous electroencephalography. Methods that are also reliable and readily applicable, but less relevant clinically, include cerebral microdialysis of fluid from the extracellular space, determination of the parenchymal oxygen tension, and determination of the venous oxygen saturation. Other techniques that are not clinically applicable include: determination of the cerebral blood flow, the cortical tissue perfusion or the regional cerebral oxygenation.

Hypophosphatemia and hypomagnesemia induced by cooling in patients with severe head injury.

OBJECT: Induced hypothermia in patients with severe head injury may prevent additional brain injury and improve outcome. However, this treatment is associated with severe side effects, including life-threatening cardiac tachyarrhythmias. The authors hypothesized that these arrhythmias might be caused by electrolyte disorders and therefore studied the effects of induced hypothermia on urine production and electrolyte levels in patients with severe head injury. METHODS: Urine production, urine electrolyte excretion, and plasma levels of Mg, phosphate, K, Ca, and Na were measured in 41 patients with severe head injury. Twenty-one patients (Group I, study group) were treated using induced hypothermia and pentobarbital administration, and 20 patients (Group 2, controls) were treated with pentobarbital administration alone. In Group 1, Mg levels decreased from 0.98+/-0.15 to 0.58+/-0.13 mmol/L (mean +/- standard deviation; p < 0.01), phosphate levels from 1.09+/-0.19 to 0.51+/-0.18 mmol/L (p < 0.01), Ca levels from 2.13+/-0.25 to 1.94+/-0.14 mmol/L (p < 0.01), and K levels from 4.2+/-0.59 to 3.6+/-0.7 mmol/L (p < 0.01) during the first 6 hours of cooling. Electrolyte levels in the control Group 2 remained unchanged. Electrolyte depletion in Group I occurred despite the fact that moderate and, in some cases, substantial doses of electrolyte supplementation were given to many patients, and supplementation doses were often increased during the cooling period. Average urine production increased during the cooling period, from 219+/-70 to 485+/-209 ml/hour. When the targeted core temperature of 32 micro C was reached, urine production returned to levels that approximated precooling levels (241+/-102 ml/hour). Electrolyte levels rose in response to high-dose supplementation. In the control group, urine production and electrolyte excretion remained unchanged throughout the study period. CONCLUSIONS: Induced hypothermia is associated with severe electrolyte depletion, which is at least partly due to increased urinary excretion through hypothermia-induced polyuria. This may be the mechanism through which induced hypothermia can lead to arrhythmias. When using this promising new treatment in patients with severe head injury, stroke, or postanoxic coma following cardiopulmonary resuscitation, prophylactic electrolyte supplementation should be considered and electrolyte levels should be monitored frequently.

Hypomagnesemia and hypophosphatemia at admission in patients with severe head injury.

OBJECTIVE: Low serum levels of electrolytes such as magnesium (Mg), potassium (K), calcium (Ca), and phosphate (P) can lead to a number of clinical problems in intensive care unit (ICU) patients, including hypertension, coronary vasoconstriction, disturbances in heart rhythm, and muscle weakness. Loss of these electrolytes can be caused, among other things, by increased urinary excretion. Cerebral injury can lead to polyuresis through a variety of mechanisms. We hypothesized that patients with cranial trauma might be at risk for electrolyte loss through increased diuresis. The objective of this study was to assess levels of Mg, P, and K at admission in patients with severe head injury. DESIGN: We measured plasma levels of Mg, P, K, Ca, and sodium at admission in 18 consecutive patients with severe head injury admitted to our ICU (group 1). As controls, we used 19 trauma patients with two or more bone fractures but no significant cranial trauma (group 2). SETTING: University teaching hospital. PATIENTS: Eighteen patients with severe head injury admitted to our surgical ICU (group 1) and 19 controls (trauma patients with no significant cranial trauma; group 2). MAIN RESULTS: Electrolyte levels at admission (group 1 vs. group 2; mean +/- SD, units: mmol/L) were as follows. Mg, 0.57 +/- 0.17 (range, 0.24-0.85) vs. 0.88 +/- 0.21 (range, 0.66-1.42 mmol/L; p < .01). P, 0.56 +/- 0.15 (range, 0.20-0.92) vs. 1.11 +/- 0.15 (range, 0.88-1.44 mmol/L; p < .01). K, 3.54 +/- 0.59 (range, 2.4-4.8) vs. 4.07 +/- 0.45 (range, 3.6-4.8 mmol/L; p < .02). Ca, 2.02 +/- 0.24 (range, 1.45-2.51) vs. 2.14 +/- 0.20 (range, 1.88-2.46; p = NS). In group 1, 12/18 patients had Mg levels <0.70 mmol/L vs. 2/19 patients in group 2 (p < .01); in group 1, 11/18 patients had P levels below 0.60 mmol vs. 0/19 patients in group 2 (p < .01). Moderate hypokalemia (K levels, <3.6 mmol/L) was present in 8/18 patients in group 1 vs. 1/19 patients in group 2 (p < .01). Severe hypokalemia (K levels, < or =3.0) was present in 4/18 patients in group 1 vs. 0/19 patients in group 2 (p < .05). CONCLUSION: We conclude that patients with severe head injury are at high risk for the development of hypomagnesemia, hypophosphatemia, and hypokalemia. One of the causes of low electrolyte levels in these patients may be an increase in the urinary loss of various electrolytes caused by neurologic trauma. Mannitol administration may be a contributing factor. Intensivists should be aware of this potential problem. If necessary, adequate supplementation of Mg, P, K, and Ca should be initiated promptly.